Ill mental health is a massive global burden, but not a crisis

Swiss Re Institute organized the Expert Forum on Mental Health, bringing together some of the knowledge leaders across the globe with Swiss Re's L&H experts - this was a full-day gathering of insights and surprises, comprised of keynotes, interviews, panel conversations and an afternoon spent in workshop-mode, focused on underwriting, claims and product design.

Led by Swiss Re Institute's Christoph Nabholz (Head of Life & Behavior R&D) and Alison McLean (Head Behavioral Research), the forum was all about bringing expert views to bear for a fruitful exchange on the current mental health landscape and factors affecting prevention and treatment of mental health-related conditions. Every which way you look at it, mental health is an important topic for Swiss Re and one where we absolutely can help to make the world more resilient.

Simon Wessely, Professor of Psychological Medicine and Regius Professor of Psychiatry, King’s College London, delivered the opening keynote, broadly termed "Overview and update on mental health" ... and it was most certainly sweeping! He began like this: "I'm here because you're wondering whether you are keeping up with what is happening with the rest of society. You're also being told that there's a crisis going on in mental health and you're wondering about that, too, and how you should respond. Well, don't worry – I'm not going to tell you how you should respond. The answer is nobody really knows." Well, he may not have all the answers, but he clearly has a great many insights. To begin with he made two things clear: 1) that understanding of - and tolerance for - mental disorders has dramatically improved over the course of the past thirty years and 2) that, contrary to popular belief, there is no dramatic rise in the prevalence of most mental disorders (he would later focus on the one exception to that).

There is no general mental health crisis

Professor Wessely has been leading the UK government's charge to review the Mental Health Act legislation. When that same was done three decades ago, the main focus had been on "public safety and public protection". "The mentally ill were seen as dangerous and thus public protection needed to be strengthened. That was the view of politicians at the time." He called the change from then to now a sea change - but over the course of his presentation he also cautioned several times, saying that the inflationary use of mental health in the press can have negative effects – as Ministers of Finance across the world are fond of reminding us, inflation leads to devaluation, and there is a danger that this is happening to, for example, those with the more severe forms of mental illness. He reminded us that "mental health runs the risk of actually being fashionable". Now, is mental health a global challenge? Absolutely. He showed a chart depicting the global burden of disease - and neuro-psychiatric diseases make up the largest slice of the pie with 28% (by comparison cancer makes up 11%).

"We now know that mental illness is the largest cause of preventable disability and a massive contributor to mortality."

It is also known that mental health disorders contribute to physical challenges such as obesity ... and still, except for one particular element, there is really nothing new when it comes to mental health. The professor put it quite bluntly, saying that: "There is nothing new with regard to the claim that we are in a crisis, nothing at all. Mental health in general and psychiatry in particular is always being depicted in crisis – it goes with the territory."

The recurring cries of "health care crisis" come about because of a systematic bias, and because of a "complete ignorance of history", as he called it. The professor pointed out that any Google search of a profession, together with the search term "mental health", will invariably bring up news about an apparent crisis in that particular field, whether it be farming or accounting or policing. He produced an arresting slide just made up of headlines from the last few weeks to make his point.

Professor Wessely explained a bias in profession surveys that is consistently large, simply because the surveys start with a focus on profession X or Y - and then introduce a mental health questionnaire. But when you do instead recruit a large random population sample, as in a census, use the same mental health questionnaire and then almost as an afterthought ask people to name their profession, you get a very different (and always better) result. But a survey focused on stress in farmers, or well-being in doctors, will invariably find ”evidence” for the crisis. He called it a “framing” effect, and one that leads to a systematic over estimation of the true rates.

Every generation ignores history

The professor always brought it back to the big picture, the broader view and the long-term view. When looking at mental health in that way, there is just about nothing that's dramatically changed. The "ignorance of history" is by and large due to generational thinking, he says: "Every generation always believes that life is tougher, harder and more complicated than that of the previous generation." To illustrate the point, he showed what life for a Victorian-age worker was like and what their challenges were, with examples such as industrial accidents, working conditions, job uncertainty, etc. He then put a particular focus on children, where, he said, the word "crisis" appears most often these days. There, too, he began by saying that the statistical numbers of severe mental health conditions such as schizophrenia, autism, bipolar, etc. have remained unchanged. But what has also changed is a) recognition b) willingness to seek help and c) definitions.

Social media is not the culprit

In particular when it comes to children and young adults, "mental health crisis" often comes up. The professor pointed out that, for the most part, rates are stable. The UK's long-running mental health survey program (started in 1993) even shows that among adolescents both smoking and drinking alcohol has markedly decreased. I can't help but feel that there's a larger media bias at work in all of this as well - it's a simple truth we hate to admit to each other - bad news sells - good news, not so much. Professor Wessely did show one area where there really is a negative development: Common mental disorders (depression and anxiety) are seeing a fairly dramatic increase in young women, aged 16-24. There's no doubt an explanation for why that is (the professor suggested that over-defensive parenting might be one cause), but there is, according to Wessely, an abundance of evidence proving that social media is not the major culprit. It is our go-to villain, isn't it? This was a surprising statement for many in the room. Asked to elaborate, the professor shared that, yes, there is a connection between social media and depression. But it isn't that social media causes depression, it is more the other way around - namely that people with depression use more social media. Overall, if there is a negative effect, it is fairly small. In contrast the negative effects of child abuse or bullying are an order of magnitude greater. Yet it is social media that attracts all the, well, media. And while there is nothing good that can be said about bullying or abuse, there are plenty of mental health benefits to social media, as well as a downside. After all, promoting social networks is well known to improve mental health and resilience – it was not for nothing that the famous film about Facebook was called ”The Social Network”.

Equal respect, commitment and care

The professor talked about an excellent effort in the UK, something called "Parity of Esteem". I very much like the idea - this is all about treating mental illness and physical illness with the same respect, the same commitment, respect and the same level of care. More about this here . At the same time the professor urged to never say that a physical illness is like a mental illness - and he highlighted a popular post written on the subject by an affected person - well worth reading! 

As everything he had shared during his keynote had been focused on the UK, he closed by broadening the scope to give a view across Europe - and showed that there is, surprisingly, a higher prevalence of young people affected by poor mental health in Scandinavian countries. This may seem counter-intuitive as these countries are known to be more advanced than other European nations in many ways, especially also in social care. So why is that, you ask? Professor Wessely suggested that it doesn't have to do with actual higher rates of mental health illness, but that instead it is about the bigger issue of "shifting boundaries". Today, when students are asked about mental health problems (something he often does during university talks), two thirds of the people in the room usually raise their hands - that is because today far more is considered a mental health problem. A student might identify himself as someone suffering from a mental health condition, but it could be homesickness, exam stress, loneliness and more. The professor urges universities to not add more and more counseling offers for students, but to instead increase social network systems such as volunteering activities, sports, drama, music - everything that brings people together. There is higher awareness by students and there are shifting perceptions ... but the body of mental health experts is equally to blame for the shifting boundaries. The DSM (Diagnostic and Statistical Manual of Mental Disorders) used to recognize 22 psychiatric disorders in 1937 (a number the professor considers suitable) - that same manual today recognizes 370 disorders!

He also reminded us of the importance of never assuming that any intervention is always a “good thing”, and that anyone who claims that they have developed a mental health intervention that has no side effects should be immediately shown the door. Any intervention that does good also does harm – it is simply a question of deciding the balance between the two. He used the example of single session psychological debriefing – when people are given a one session counselling intervention in the immediate aftermath of exposure to a major traumatic event – assault, terrorism, serious injury and so on. Here everyone thought this had to be a "good thing" – what could possibly go wrong? But when the randomized trials were finally done, it turned out that a lot could go wrong, and that overall it increased, not decreased, the risk of mental disorder later on. Professor Wessely highlighted: "Instead, people already seem to do the right thing in such situations – after the 2005 terrorist bombs in London only 2% expressed a need for immediate mental health support, whilst nearly everyone turned to – you've guessed it – their social network." It was only when they were unable to make contact with family and friends that their anxiety increased. What was surprising was that those people were still more anxious six months later. Mobile phones may not be so bad after all.

To sum it up: A great deal has been learned and improved upon in the past decades. Beyond understanding it has also led to shifting boundaries - and to greater mental health awareness that leads to more and more people seeking help. The global burden of mental health illnesses is immense and will continue to increase – but overall there are no dramatic rate changes and we should avoid overstating the case, as when people talk about, for example, a pandemic of mental health problems. That just not helpful, the professor said and added in closing: "We overestimate the impact and we underestimate the essential resilience of normal people."